With all of the factors that go into the state's nursing care facility inspection process, it's easy for some people shopping for a facility for their loved ones to become overwhelmed.

On the federal level, the Center for Medicare Services has created an overall standard for the quality of care provided by these accredited facilities, a five-star rating system that strives to provide a snapshot for potential customers.

But industry experts say the system misrepresents some of the facilities in less populated areas of the state, including the Poconos.

"I just don't agree with (the system) at all," said Vince Urban, the nursing administrator for Brookmont Health Care. "We're not perfect, no, but, in 10 years of working as a health care administrator, I have never understood how they come up with their numbers."

Brookmont's overall rating is 2 out of 5, which is considered "below average" by CMS.

The Effort facility is not alone in bearing this seemingly low rating, however.

None of the six facilities in the Monroe and Pike area have a score above 2 out of 5. In other words, all of the facilities are considered below average in the eyes of the federal government.

"Medicare's rating system is broken," said Russ McDaid, the vice president of public policy for LeadingAge PA, an advocacy group that works closely with nonprofit nursing care facilities.

"The northeastern part of the state has a low number of five-star rated homes, but that doesn't mean that they're not good facilities. Out of the gate, these homes are starting with a lower score, and it's hard to earn those back."

Medicare's metric is based on three factors: the results from the state's annual inspection reports (see the main story for more information), quality measures and staffing.

Each of these factors is assigned its own five-star rating, which are then combined through specific formulae to create the nursing care facility's overall rating.

The first third of the overall rating, the inspection report rating, is created through a point system that incorporates how well a given facility performs during its inspections.

Points are given based on the number, scope and severity of the deficiencies listed in the facility's inspection reports, with a lower score resulting in a better rating.

Facilities are ranked within their state based on their score, and the number of stars they receive is based on their position within that ranking: The top 10 percent get five stars, the bottom 20 percent get one star and the middle 70 percent receive two, three or four stars.

This final inspection rating is the most heavily weighted portion of the overall rating, and is the foundation upon which the facility's five-star score is built.

Stars are either added or removed from the inspection rating based on how well the facility scores on the two remaining sub-ratings, which measure how well the facility cares for patients with specific medical conditions (quality measures) and how many staffing hours per day the facility provides for its residents (staffing).

If the facility has a five-star quality measure rating, an additional star gets added to its inspection result rating; conversely, a star is subtracted if the facility has a one-star quality measure rating.

Similarly, if the facility's staffing rating is four or five stars, an additional star is added to the inspection rating, and, again, a star is subtracted if the facility has a one-star staffing rating.

With the way the rating system operates, Pocono-area facilities that have high star ratings in the latter two categories — such as Brookmont, which boasts a four-star quality measure rating — are pulled down overall by their low inspection result ratings, a function of the facilities' relatively small size and the comparatively high number of deficiencies found by the facilities' inspectors.

"It's a complicated system," Vince Urban said, "one that I don't think many residents or their families give much weight — I have never had someone come to me with concerns over our star rating."

Golden LivingCenter Stroud in East Stroudsburg is in a similar situation: The facility has a perfect, five-star score on its quality measure rating, but gets pulled down to a one-star rating overall due to its low inspection results and staffing ratings.

"We are all fortunate as an industry and as a public to have some of these rating systems," said Kelli Luneborg, a spokesperson for Golden LivingCenters. "Are they complex? Yes. Are they stringent and hard on the industry? They're meant to be."

Luneborg said Golden LivingCenters supports the CMS system and embraces it as a tool for improving the facilities' overall quality of service.

"As a consumer, I wouldn't want a test that any facility could pass with flying colors all the time, every time; they're should always room for improvement," she said.

But those working closely with the data still argue that the rating is, much like the state's inspection reports, just one tool available to consumers to use, and shouldn't be considered by itself.

"There is no substitute for visiting a facility yourself and speaking to family members and residents who are already there," McDaid said. "If you're comfortable after those conversations, but the facility only has a two- or three-star rating, you can still feel comfortable.

"And on the other side, even if facility has five stars, you can still pick up red flags."